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New Hampshire utilized a waiver to implement its own version of Medicaid expansion, but the state stopped purchasing private coverage for Medicaid enrollees as of 2019, and transitioned to standard Medicaid instead.

In New Hampshire, short-term plan duration is limited to six months with no renewal.

New Hampshire’s health insurance marketplace

How hard has New Hampshire tried to preserve the Affordable Care Act’s gains? See how New Hampshire compares to other states.

New Hampshire’s partnership exchange relies on the federal platform – HealthCare.gov – for application and enrollment, but the state operates Covering New Hampshire, which serves as a resource for those who purchase health insurance in the individual market.

New Hampshire individual market insurers and enrollment data

44,412 people enrolled in private plans through New Hampshire’s exchange during the open enrollment period for 2020 coverage. Although that was only a slight decline from 2019 (when 44,581 people enrolled), it was the fourth straight year of declining enrollment, and was down from more than 55,000 enrollees in 2016.
Three insurers – Ambetter, Anthem, and Harvard Pilgrim – are offering 2020 individual health plans through New Hampshire’s exchange. Final premium rate changes approved for the three were:

New Hampshire Medicaid expansion

New Hampshire expanded Medicaid in 2014, but used an 1115 waiver to allow for a different approach to Medicaid expansion than the one outlined in the ACA. Senate Bill 413 was signed into law by Governor Hassan in March 2014, and called for Medicaid expansion to begin that summer, with residents able to begin applying on July 1. The coverage gap in New Hampshire was eliminated once the state became the 26th to expand Medicaid under the ACA.

By August 2015, total New Hampshire Medicaid/CHIP enrollment had grown 47 percent since 2013 – the 12th biggest change nationwide. Enrollment plateaued and began to decline after that, with net enrollment growth 39 percent higher in late 2019 than it had been in late 2013.

Until the end of 2015, Medicaid expansion in New Hampshire was following the program outlined in the ACA, and all legal residents with household incomes up to 138 percent of poverty were eligible to receive Medicaid coverage. But starting in January 2016, the state transitioned to a privatized version of Medicaid expansion (i.e., Premium Assistance Program), using Medicaid funds to subsidize private coverage. When the state had passed its Medicaid expansion bill, the legislature had a Republican majority, and the privatized approach to Medicaid expansion fit a more conservative mold.

By 2018, PAP membership hovered around 50,000 people. But New Hampshire opted to abandon the PAP approach and move to a traditional Medicaid managed care system for Medicaid expansion enrollees. The state received federal permission to implement the Granite Advantage Health Care Program in January 2019, and also received separate federal permission to implement a Medicaid work requirement (the work requirement took effect in January 2019, but was subsequently overturned by a federal judge and is not in effect as of early 2020; New Hampshire’s House of Representatives voted to remove the work requirement in early 2020). So New Hampshire no longer purchases private plans in the exchange for Medicaid expansion enrollees; they are enrolled in the Granite Advantage Health Care Program instead.

Short-term health insurance in New Hampshire

New Hampshire has state regulations pertaining to short-term health insurance that limit short-term plan duration to six months with no renewal. (Enrollees are allowed to apply for a new short-term plan that takes effect after the first plan ends, but it has to be a new, separate plan, with a new deductible and out-of-pocket exposure.

But a short-term plan cannot be issued to anyone who has had more than 540 days of short-term coverage in the past two years. So a person can’t have more than a year and a half of short-term coverage in a given two-year period.

Trust for America’s Health provides yet another look at overall public health in New Hampshire in their 2017 listing of Key Health Data About New Hampshire. Their summary includes socioeconomic health indicators, access to care, and the prevalence of various illnesses and health outcome predictors.

You can also see how the ten counties in New Hampshire compare with one another in terms of health factors and outcomes, using this interactive map created by the Robert Wood Johnson Foundation.

New Hampshire and the Affordable Care Act

In 2010, New Hampshire’s U.S. Senators were split on the ACA. Democrat Jeanne Shaheen voted yes, while Republican Judd Gregg voted no. In the U.S. House, Carol Shea-Porter and Paul Hodes, both Democrats, voted yes.

Shaheen is still in the Senate, but Gregg was subsequently replaced by Kelly Ayotte, a fellow ACA opponent, who was in office until 2017. Ayotte was replaced in 2017 by Maggie Hassan, former governor of New Hampshire and a supporter of the ACA. In the House, Ann Kuster replaced Hodes in 2013. She is an ACA supporter who wants to keep the law but improve upon it. Chris Pappas, also a Democrat, joined Kuster in the House as of 2019. Pappas supports measures to strengthen the ACA and then go beyond it towards a system of universal coverage, including the possibility of a public option and/or allowing people to buy into Medicare.

In the 2014 Senate race, Shaheen was one of relatively few Democrats who fully embraced the ACA and the changes it has brought about. She defended the law, saying it was “absolutely” an achievement of which she is proud. Shaheen won re-election against Republican opponent Scott Brown in 2014. And Hassan defeated Ayotte in the 2016 election, with support for the ACA and New Hampshire’s Medicaid expansion included in her platform.

At the state level, the legislature currently has a Democratic majority. Governor Chris Sununu, who replaced Hassan in 2017, is a Republican, but has a more measured approach to the ACA than many in the GOP. Sununu would prefer that the federal government give states more latitude in designing their own health care regulations, but he was opposed to Senate Republicans’ 2017 effort to repeal the ACA, particularly the Medicaid funding cuts that would have been part of that legislation. Sununu also asked the Trump Administration to take action to help stabilize the individual insurance markets in 2017.

How has Obamacare helped New Hampshire residents?

New Hampshire operates a state-partnership exchange and expanded Medicaid, both typical of states that have embraced the Affordable Care Act. New Hampshire expanded Medicaid as of July 2014 — six months after expansion became available in many other states, but well ahead of numerous other states, 15 of which still have not expanded Medicaid as of 2020.

According to U.S. Census data, the uninsured rate in New Hampshire was 10.7 percent in 2013, which was well below the national average of 14.5 percent at that point. By 2016, the uninsured rate in New Hampshire stood at 5.9 percent – still well below the U.S. average of 8.6 percent. It dropped as low as 5 percent in 2017, although it had grown to 5.7 percent by 2018, mirroring the national trend of increasing uninsured rates under the Trump administration.

Young adults can remain on their parents’ health plans until age 26 as a result of the ACA, and health insurance companies no longer base eligibility or premiums on applicants’ medical history.

Does New Hampshire have a high-risk pool?

Before the ACA reformed the individual health insurance market, coverage was underwritten in nearly every state, including New Hampshire. This meant that pre-existing conditions could result in an applicant being rejected for coverage, or offered a plan with significantly higher premiums or policy exclusions. The New Hampshire Health Plan (NHHP) was created in 2002 to provide an alternative for residents with pre-existing conditions who were not eligible to purchase private individual health insurance because of their medical history.

But the ACA brought significant changes to the individual health insurance market, including a ban on medical underwriting; all policies are now guaranteed issue, in all states. This meant that high-risk pools are no longer necessary the way they once were, since applicants with pre-existing conditions now have the same insurance choices as the rest of the population.

NHHP was originally slated to cease operations at the end of 2013, but the troubled rollout of Healthcare.gov meant that many members were unable to purchase new coverage by the start of 2014. As a result, NHHP continued to provide coverage until June 30, 2014. At that point, any remaining policies terminated, giving members a 60-day special enrollment period during which they could purchase a new plan (involuntary loss of other coverage is a qualifying event that triggers a special enrollment period).

Medicare enrollment in New Hampshire

New Hampshire Medicare enrollment reached 300,374 by late 2019, which was about 22 percent of the state’s population compared with nearly 19 percent of the total U.S. population enrolled in Medicare. New Hampshire is among the states with the highest percentage of population enrolled in Medicare (New Hampshire’s population is also older than the US average).

Eighty-three percent of New Hampshire Medicare enrollees qualify based on age alone, while the other 17 percent are eligible for Medicare as a result of a disability.

As of 2017, Medicare’s annual per-beneficiary spending in New Hampshire was $8,380, which was 14 percent lower than the national average.

State-based health reform legislation

S.B.313, enacted in New Hampshire in 2018, called for restructuring the state’s Medicaid expansion program to use Medicaid managed care – as most of the country does – instead of the Premium Assistance Program. This was implemented in 2019.

Scroll to the bottom of the page for a summary of other recent health reform-related bills in New Hampshire.